The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 20 of 89 Results

Middle manager responses to hospital co-workers' unprofessional behaviours within the context of a professional accountability culture change program: a qualitative analysis.

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Bagot KL, McInnes E, Mannion R, et al. BMC Health Serv Res. 2023;23:1012.

Unprofessional behavior can have a detrimental effect on coworkers, culture, and patient safety. This qualitative study presents perspectives of middle managers in hospitals that implemented a program allowing and encouraging workers to report unprofessional, as well as positive, behavior. Themes included staying silent but active (e.g., avoiding the unprofessional colleague), history and hierarchy, and double-edged swords (e.g., pros and cons of anonymous reporting).

Innovative approaches to analysing aged care falls incident data: International Classification for Patient Safety and correspondence analysis.

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Seaman K, Meulenbroeks I, Nguyen A, et al. Int J Qual Health Care. 2023;35:mza080.

Patients in long-term or residential care facilities are at high risk of falls. In this study, researchers applied the International Classification for Patient Safety (ICPS) criteria to categorize types of falls occurring in residential aged care facilities in Australia. Falls requiring hospitalization more often occurred in residents’ bedrooms or communal areas. Resident pre-existing psychological or physical health were the most common contributing factor in falls that required a hospitalization.

The delivery of safe and effective test result communication, management and follow-up.

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Georgiou A, Li J, Thomas J, et al. Public Health Res Pract. 2023;33:e3332324.

Several systemic factors may hinder communication of test results to patients and clinicians. This article describes a research project in Australia, "Delivering safe and effective test result communication, management and follow-up." Along with previously identified test result communication challenges such as workflow and technology, this paper highlights the need for national thresholds for critical laboratory results.

Speaking up as an extension of socio-cultural dynamics in hospital settings: a study of staff experiences of speaking up across seven hospitals.

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Pavithra A, Mannion R, Sunderland N, et al. J Health Org Manag. 2022;36:245-271.

Speaking up behaviors among healthcare workers is indicative of psychological safety and a culture of safety. This survey of healthcare staff working at seven sites across one hospital network in Australia found that speaking up behaviors are influenced by whether staff feel empowered in their roles and supported by their peers and supervisors.

Short- and long-term effects of an electronic medication management system on paediatric prescribing errors.

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Westbrook JI, Li L, Raban MZ, et al. NPJ Digit Med. 2022;5:179.

Pediatric patients are particularly vulnerable to medication errors. This cluster randomized controlled trial examined the short- and long-term impacts of an electronic medication management (eMM) system implemented at one pediatric referral hospital in Australia. Findings suggest that eMM implementation did not reduce medication errors in the first 70 days of use, but researchers observed a decrease in medication errors one year after implementation, suggesting long-term benefits.

Changes in unprofessional behaviour, teamwork, and co-operation among hospital staff during the COVID-19 pandemic.

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Westbrook JI, McMullan R, Urwin R, et al. Intern Med J. 2022;52:1821-1825.

The COVID-19 pandemic dramatically impacted team functioning in healthcare settings. This survey of nearly 1,600 clinical and non-clinical staff at five Australian hospitals did not identify any perceived increases in unprofessional behaviors during the pandemic and 44% of respondents cited improvements in teamwork.

Outcome differences between surgeons performing first and subsequent coronary artery bypass grafting procedures in a day: a retrospective comparative cohort study.

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Zhang D, Gu D, Rao C, et al. BMJ Qual Saf. 2023;32:192-201.

Clinician workload has been linked with poor patient outcomes. This retrospective cohort study assessed the outcomes for patients undergoing coronary artery bypass graft (CABG) performed as a surgeons’ first versus non-first procedure of the day. Findings suggest that prior workload adversely affected outcomes for patients undergoing CABG surgery, with increases in adverse events, myocardial infarction, and stroke compared to first procedures.

Morbidity and mortality caused by noncompliance with California hospital licensure: immediate jeopardies in California hospitals, 2007-2017.

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Zheng MY, Lui H, Patino G, et al. J Patient Saf. 2022;18:e401-e406.

California law requires adverse events that led to serious injury or death because of hospital noncompliance to be reported to the state licensing agency. These events are referred to as “immediate jeopardy.” Using publicly available data, this study analyzed all immediate jeopardy cases between 2007 and 2017. Of the 385 immediate jeopardy cases, 36.6% led to patient death, and the most common category was surgical.

Rates of serious surgical errors in California and plans to prevent recurrence.

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Cohen AJ, Lui H, Zheng M, et al. JAMA Netw Open. 2021;4:e217058.

… use of intraoperative checklists. … Cohen AJ, Lui H, Zheng M, et al. Rates of serious surgical errors in …

Are operating room distractions, interruptions, and disruptions associated with performance and patient safety? A systematic review and meta-analysis.

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Mcmullan RD, Urwin R, Gates PJ, et al. Int J Qual Health Care. 2021;33:mzab068.

Distractions in the operating room are common and can lead to errors. This systematic review including 27 studies found that distractions, interruptions, and disruptions in the operating room are associated with a range of negative outcomes. These include longer operative duration, impaired team performance, self-reported errors by colleagues, surgical errors, surgical site infections, and fewer patient safety checks.

The impact of introducing automated dispensing cabinets, barcode medication administration, and closed-loop electronic medication management systems on work processes and safety of controlled medications in hospitals: a systematic review.

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Zheng WY, Lichtner V, Van Dort BA, et al. Res Soc Admin Pharm. 2021;17:832-841.

This systematic review sought to determine the impact of automated dispensing cabinets (ADCs), barcode medication administration (BCMA), and closed-loop electronic medication management systems (EMMS) used by hospitals in reducing controlled substance medication errors in hospitals. Overall, only 4 studies (out of 16) focused directly on controlled medications. A variety of types of errors (e.g., log-in, data, entry, override) compromised patient safety. High-quality targeted research is urgently needed to evaluate the risks and benefits of medication-related technology.

Racial/ethnic disparities in interhospital transfer for conditions with a mortality benefit to transfer among patients with Medicare.

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Shannon EM, Zheng J, Orav EJ, et al. JAMA Network Open. 2021:4(3);e213474.

This cross-sectional study examined whether racial/ethnic disparities in interhospital transfers (IHT) for common medical diagnoses such as heart failure, acute myocardial infarction, stroke, and sepsis, impact mortality outcomes. The authors analyzed 899,557 patients and reported that Black patients had lower odds of IHT compared to White patients, while Hispanic patient had higher odds of IHT compared with White patients. The authors propose several possible explanations including differences in Black and Hispanic willingness to transfer, impact of insurance status and reimbursement rates, coding inaccuracies, and other complex dynamics for their findings.

Work effort, readability and quality of pharmacy transcription of patient directions from electronic prescriptions: a retrospective observational cohort analysis.

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Zheng Y, Jiang Y, Dorsch MP, et al. BMJ Qual Saf. 2020;30:311-319.

Clinicians commonly use free-text to generate electronic prescriptions (e-prescriptions); however, these e-prescriptions often require double-checking and transcription by pharmacist staff to avoid potential medication errors. This retrospective study found that about half of the patient directions on e-prescriptions contained at least one quality issue (e.g., dose, frequency of administration) and that pharmacy staff spend significant time and effort identifying and correcting these issues.

Medication errors related to computerized provider order entry systems in hospitals and how they change over time: a narrative review.

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Kinlay M, Zheng WY, Burke R, et al. Res Social and Adm Pharm. 2021;17:1546-1552.

Computerized provider order entry (CPOE) systems have been advocated as a strategy to reduce medical errors, but some errors persist. This narrative review identified knowledge gaps in the relationship between CPOE systems and how systems-related errors change over time. Studies suggest that system-related errors persist with long-term use of CPOE systems, but future research should explore the types of errors that occur, when they occur, and the system factors contributing to the errors.

Patient Safety

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Zheng F ed. Surg Clin North Am. 2021;101(1):1-160.

Surgical safety is a recognized area of emphasis in patient safety improvement. Articles in this special issue cover topics such as human factors, checklists, teamwork, and telemedicine as a safe support mechanism.

Safety of surgical telehealth in the outpatient and inpatient setting.

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Purnell S, Zheng F. Surg Clin North Am. 2020;101:109-119.

COVID-19 restrictions and patient concerns have expanded access to telemedicine worldwide. This review examines the use of telemedicine in surgical services. The authors found it to be a safe care modality for low-risk patients receiving low-risk procedures. They found that telemedicine in surgical services evidence base is expanding and its value is built on local, real-time approaches that involve services designed to consider patient needs and comfort.

How effective are electronic medication systems in reducing medication error rates and associated harm among hospital inpatients? A systematic review and meta-analysis.

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Gates PJ, Hardie R-A, Raban MZ, et al. J Am Med Inform Assoc. 2021;28:167-176.

… J Am Med Inform Assoc … Electronic prescribing systems (such … inpatients? A systematic review and meta-analysis. J Am Med Inform Assoc … . … Epub 2020 Nov 10. …

Weekend effect on in-hospital mortality for ischemic and hemorrhagic stroke in US rural and urban hospitals.

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Mekonnen B, Wang G, Rajbhandari-Thapa J, et al. J Stroke Cerebrovasc Dis. 2020;29:105106.

… J Stroke Cerebrovasc Dis … The ” weekend effect ” refers to … rural regions. … Mekonnen B, Wang G, Rajbhandari-Thapa J, et al. Weekend effect on in-hospital mortality for … and hemorrhagic stroke in US rural and urban hospitals. J Stroke Cerebrovasc Dis. 2020;29(10):105106. Epub …

Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients.

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Westbrook JI, Li L, Raban MZ, et al. BMJ Qual Saf. 2021;30:320-330.

The researchers in this study directly observed nurses administering medications to pediatric patients to measure the association between double-checking and medication administration errors. When double-checking was mandated, the researchers did not find any significant association with medication errors. When double-checking was not mandated but was performed, medication administration errors were less likely to occur and were less severe, but the association was not significant. These findings raise questions about the benefits compared to single-checking.

Variation in electronic test results management and its implications for patient safety: a multisite investigation.

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Thomas J, Dahm MR, Li J, et al. J Am Med Inform Assoc. 2020;27:1214–1224.

This qualitative study explored how clinicians ensure optimal management of diagnostic test results, a major patient safety concern. Thematic analyses identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality.

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